Public Health Under the Scope

With anthrax exposures and infections mounting, the powers of public health face a new and daunting test--and the weaknesses of the system have come under a glaring light.

The system's defects, brought on by years of budget cuts, are on display: Labs are easily overwhelmed, and strapped health departments are hurriedly diverting resources from chronic diseases and more routine infections.

A quarter of public health agencies don't even have a plan to deal with disaster; 15 states lack state epidemiologists, detectives who study the cause and spread of diseases.

The newness of the anthrax threat has forced public health authorities to rely on trial and error to respond. Critics say two postal workers died this week because health authorities made the mistake of screening too few people for the deadly disease.

Public health experts say the criticism is unfair.

"We haven't dealt with anything like this before," said Dr. Allan Rosenfield, dean of the Mailman School of Public Health at Columbia University in New York. "You do learn on these things as you go along."

At the same time, public health workers are being forced to adapt to an entirely new culture. Used to toiling in relative obscurity, they are suddenly working side by side with law enforcement in a high-profile, high-pressure investigation. Their enemy is not the usual accidental outbreak but a tiny deadly bacterium, deliberately delivered.

"Most of the things we deal with don't assume sinister motives," said Dr. Jonathan Fielding, Los Angeles County's top public health officer. "Basically, bioterrorism is a new chapter."

One example of the cultural mismatch between disease experts and federal agents: Public health officials like to disseminate information as quickly as possible to alert the public to risks.

But in the anthrax investigation, law enforcement officials have been slow to share information with public health authorities or have deemed it confidential. So it was that health agencies were among the last to learn that the anthrax found in the office of Senate Majority Leader Tom Daschle (D-S.D.) was weapon-grade.

"The FBI has its particular concerns with developing material for a criminal prosecution, and they're not obviously terribly happy about revealing everything they've found," said Dr. D.A. Henderson, head of the bioterrorism advisory committee at the U.S. Department of
Health and Human Services. "For us in public health, on the other hand, to get all the information out there is very key. So there we are. We're kind of stuck with two cultures."

The breakdown in communication was the subject of a White House meeting Wednesday night with Director of Homeland Security Thomas J. Ridge. "We've all got to rededicate ourselves to sharing information, and as quickly as possible," HHS Secretary Tommy G. Thompson said.

Critics say public health officials have been too quick to make recommendations, only to amend or withdraw them later.

Initially, for example, officials had warned the public against taking antibiotics unless they had been exposed to anthrax spores. This week, however, federal health officials abruptly switched course and handed out pills to thousands of mail workers who may--or may not--have been near contaminated mail.

At first, public health authorities did not believe anthrax could be contracted by touching an unopened envelope. The deaths of two Washington, D.C., postal workers suggested that was wrong.

And whereas vaccinating civilians against anthrax and smallpox was not considered a viable option at the outset, some health experts are beginning to discuss it more seriously.

Public health officials say they are frustrated by criticism that they should have responded differently and more aggressively to the risks.

"This kind of Monday morning quarterbacking isn't helpful," said Dr. Paul Wiesner, director of the DeKalb County Board of Health in Georgia. "You never know about risk until you have data."

Thompson agreed. "We have good science, but it is also . . . evolving science," he said at a summit of mayors this week. "Remember, we have never had cases of anthrax attacks in this manner before. It is a new challenge that we're all facing as a country."

This is hardly the first time major health events have led to errors and oscillation by the health experts. After the first cases of AIDS were identified in 1981, for example, the public health system floundered for years before consistent messages were sent.

In the anthrax case, health officials are struggling to reassure a worried public at the same time that they are offering their own staff members crash courses on the disease, the officials point out. The public is demanding answers to questions that the officials can't always answer.

They also are forced to divert precious resources to false alarms, such as conducting lab tests on powder from doughnuts, crushed breath mints and talcum powder.

In Nashville-Davidson County, Tenn., Health Director Stephanie Bailey had to retrain 17 public health nurses to interact with the public and journalists concerning anthrax. That has funneled time and money away from immunizations and other services.

Those everyday needs haven't stopped or slowed. In the middle of dealing with anthrax anxiety, Nashville public health officials have responded to a hepatitis A outbreak and a possible case of whooping cough.

Health workers nationwide are adjusting to very different jobs. In the months before Sept. 11, biostatistician Erin Ray Pascaretti tracked the number of cardiac arrests in Dutchess County, N.Y., with the goal of improving survival rates and putting more defibrillators in public places. Pascaretti is suddenly her county's full-time bioterrorism guru.

"This is kind of exciting," compared to everyday biostatistics, she said. "But there's also a sense of urgency that makes it somewhat overwhelming."

One advantage to public health's new higher profile is that it may, over the long term, draw more government resources. The White House already has proposed spending $1.5 billion to purchase antibiotics and vaccines and provide cash infusions to state and local health departments. Several members of Congress have talked about providing even more money, especially for state and local agencies.

"There is a political will to address the public health infrastructure and gaps, even in my city," said Bailey, whose department has absorbed budget cuts for 10 consecutive years.

Said Dr. Michael Caldwell, health commissioner in Dutchess County: "My view of public health hasn't changed, but I believe the world's view of public health has changed. This incident has crystallized it so we don't have to sell it anymore."